STATE OF VERMONT. Defendant Name V. FINANCIAL AFFIDAVIT (813A) Other: Street Address (if different from Street Address)

Size: px
Start display at page:

Download "STATE OF VERMONT. Defendant Name V. FINANCIAL AFFIDAVIT (813A) Other: Street Address (if different from Street Address)"

Transcription

1 STATE OF VERMONT SUPERIOR COURT Unit Plaintiff Name DOB FAMILY DIVISION Docket No. Defendant Name DOB V. FINANCIAL AFFIDAVIT (813A) I am: Plaintiff Defendant Other: Name Street Address (if different from Street Address) Street Address Town/City State Zip Phone Number (day) Town/City State Zip Phone Number (evening) Address INSTRUCTIONS: You are required to complete and file the 813A if1. You are a party in a newly filed divorce, civil union dissolution, legal separation, annulment or parentage action and you and the other party have minor children; OR 2. You or the other party are seeking to modify a previously issued order regarding child support or spousal maintenance (alimony); OR 3. You are the person required to pay support, and an enforcement action has been filed against you; OR 4. Your child is in the custody of the Department of Children and Families and support has been requested of you; OR 5. You are ordered by the Court to complete and file this form or the other party requests that you fill out the form as part of the discovery process. DEADLINE FOR FILING: This form must be filed with the court before or at your first case manager's conference. If no conference is scheduled it must be filed at least five days before your first scheduled court hearing. YOU MUST SEND A COPY OF YOUR COMPLETED FORM TO THE OTHER PARTY AT THE SAME TIME YOU FILE IT WITH THE COURT. When you have completed the form and filled in all the required information, you must sign the Affirmation section below and have your signature notarized. AFFIRMATION I have read and filled in all the information requested. I hereby affirm of my own knowledge that the facts and financial information I have stated are true and correct as of the date of this Affirmation and that I am not omitting any source or amount of income or other information requested on this form. I understand that any false information may constitute perjury by me. I also understand that if I fail to provide the required information or give misinformation, the judge may order sanctions against me. Signature of person making affidavit Sworn to me on My Commission Expires: Signature of Notary Public Page 1 of 11

2 SECTION I - INCOME EMPLOYER NAME and ADDRESS SECOND EMPLOYER I am self-employed (sole proprietor, partnership, d/b/a) as a I am not currently employed because A. MONTHLY GROSS INCOME FROM EMPLOYMENT - Income before any deductions for payroll taxes or benefits. (If your income varies throughout the year, calculate your annual income and divide by twelve to get your monthly income in each category below.) To calculate MONTHLY amounts from paychecks: If you are paid weekly, multiply average weekly pay by If you are paid every other week, multiply average bi-weekly pay by If you are paid twice a month, multiply average semi-monthly pay by 2 ATTACH 4 MOST RECENT PAY CHECK STUBS. 1. SALARY OR WAGES I have included overtime Yes No 2. TIPS, COMMISSIONS, BONUSES, ROYALTIES 3. SELF EMPLOYMENT INCOME (Complete Self Employment Attachment on page 11 or attach IRS SCHEDULE C from tax filing) 4. PERSONAL EXPENSES PAID BY EMPLOYER (for example: cell phone, car, housing allowance, meals, military allowances) Income from Employment B. OTHER SOURCES OF INCOME (Indicate Monthly Amount) 1. RENTAL INCOME (Complete Rental Income Attachment on page 10 or attach IRS SCHEDULE E from tax filing) 2. RETIREMENT/PENSIONS 3. UNEMPLOYMENT INSURANCE BENEFITS 4. WORKER'S COMPENSATION and/or DISABILITY INSURANCE 5. SOCIAL SECURITY BENEFITS (Specify type ) 6. VETERANS BENEFITS (VA) 7. INTEREST OR DIVIDEND INCOME 8. TRUST OR ANNUITY INCOME 9. GIFTS OR PRIZE MONEY (Including lottery winnings) 10. SPOUSAL MAINTENANCE (Alimony) (From the other party in this action) 11. SPOUSAL MAINTENANCE (Alimony) (From a person not a party in this action) 12. OTHER: Please specify (For example, capital gains) Income from Other Sources TOTAL MONTHLY INCOME (Employment and Other Sources) Page 2 of 11

3 SECTION II - PUBLIC BENEFITS DO YOU RECEIVE PUBLIC BENEFITS? Yes No If yes, please check all boxes that apply and indicate dollar amount, where applicable Reach Up, RUFA, TANF Dr. Dynasaur/Blue First Fuel Assistance General Assistance Medicaid/Medicare Food Stamps SSI VHAP Housing Assistance SECTION III - INCOME/EXPENSES of MINOR CHILDREN ''Minor Children '' means children under 18 or children over the age of 18 but still in high school. A. LIST ALL MINOR CHILDREN YOU HAVE WITH THE OTHER PARTY NAME B. Current Primary Residence LIST ALL OTHER MINOR CHILDREN FOR WHOM YOU PROVIDE SUPPORT NAME C. Date of Birth Date of Birth Relationship to you Current Primary Residence LIST ALL CHILDREN FOR WHOM YOU ARE ORDERED TO PAY CHILD SUPPORT NAME Amount Ordered Amount Paid State/County of Order Page 3 of 11

4 D. HEALTH INSURANCE AVAILABLE THROUGH YOUR EMPLOYMENT: You must complete this paragraph if you could get this kind of insurance through your job even if your children are not enrolled. Check with your Payroll or Human Resources Department to obtain amount of your monthly payroll contribution to the cost. TOTAL MONTHLY FAMILY HEALTH INSURANCE COST TO EMPLOYEE TOTAL MONTHLY TWO PERSON COST TO EMPLOYEE TOTAL MONTHLY COST FOR SINGLE PERSON COVERAGE TO EMPLOYEE ARE CHILDREN OF THIS ACTION ENROLLED IN YOUR PLAN? Yes No E. YOUR CHILD CARE COSTS FOR CHILDREN OF THIS RELATIONSHIP (If monthly amounts change during the year, use total annual amount divided by 12) TOTAL MONTHLY CHILD CARE COSTS (before subsidy) TOTAL MONTHLY CHILD CARE SUBSIDY OUT OF POCKET COSTS ( costs minus subsidy) Transfer out of pocket costs to Page 9, line 51. F. YOUR EXTRAORDINARY EXPENSES FOR CHILDREN OF THIS RELATIONSHIP Type of expense Cost per month Child's Uninsured Medical expenses Child's Educational Expenses Child's Special Needs Expenses G. MONTHLY INCOME RECEIVED BY A CHILD OF THIS RELATIONSHIP INCOME SOURCE Child's Name Amount 1. DISABILITY BENEFITS 2. SOCIAL SECURITY BENEFITS 3. OTHER Name of Parent who receives the child's benefit: Page 4 of 11

5 SECTION IV - LOANS AND DEBTS LOANS A. Primary Residence Loans: Type of Loan Balance owed Lender Monthly Check here if YOU are making this 1. Primary Residence 2. Second Mortgage 3. Home Equity Primary Residence Transfer Monthly Payment to Page 7, Line 1 B. Other Real Estate Loans - DO NOT include business or rental property loans Property Description Lender Balance Owed Monthly Payment Check here if YOU are making this Other Real Estate Transfer Monthly Payment to Page 8, Line 38 C. Vehicle Loans Type of Vehicle (Year, Make, Model) Lender Balance Owed Monthly Payment Check here if YOU are making this Vehicle Loans Transfer Monthly Payment to Page 7, Line 14 Page 5 of 11

6 D. Other Loans Type of Loan Lender Balance Owed Monthly Check here if YOU are making this Personal Loan School/College Loan Other Other Transfer Monthly Payment to Page 8, Line 38 DEBTS A. Credit Card Debt Card Holder Company Balance Owed Monthly Check here if YOU are making this Transfer Monthly Payment to Page 8, Line 43 B. Other Debts (for example tax liens, hospital bills, collection accounts) Type of Debt Company/Entity Owed Balance Due Monthly if any Check here if YOU are making this Transfer Monthly Payment to Page 8, Line 38 Page 6 of 11

7 SECTION V - EXPENSES MONTHLY EXPENSES: List your monthly expenses. For those expenses paid other than monthly, take the annual amount and divide it by 12. If amount paid changes from month to month, use the annual amount divided by 12. HOUSEHOLD EXPENSES- Amount paid by you Household 1. Rent or Mortgages, including Home Equity Loans 2. Property Taxes 3. Home Owner's or Renter's Insurance 4. Electricity 5. Telephone (Land and Cell Phone) 6. Water 7. Gas for home 8. Oil, Wood or other fuel not listed above 9. Mowing, Plowing, Trash 10. Groceries 11. Cable/Internet 12. Laundry/Dry Cleaning 13. Maintenance/repair TOTAL OF HOUSEHOLD EXPENSES VEHICLE EXPENSES Amount paid by you Household you Household 14. Vehicle Loans 15. Car Insurance 16. Gas 17. Maintenance/Repairs 18. Registration TOTAL VEHICLE INSURANCE EXPENSES 19. Life Insurance 20. Disability Insurance 21. Health Insurance 22. Dental/Vision TOTAL INSURANCE Page 7 of 11

8 YOUR PERSONAL EXPENSES you 23. Uninsured Medical Expenses 24. Clothing/Shoes 25. Toiletries/Cosmetics 26. Meals/Snacks eaten out 27. Hair Care 28. Magazines, Newspapers, Books, other reading material 29. Tobacco and Alcohol Products 30. Veterinarian and other pet expenses 31. Entertainment (movies, bowling, museums, etc.) 32. Gifts for others 33. Charitable Contributions 34. Vacation 35. Union Dues 36. Monthly Contribution to Savings 37. Monthly Contribution to Retirement Funds (401K, IRA, etc.) 38. Monthly Loan & Debt Payments (do not include primary residence loans, credit cards, or vehicle s) 39. Expenses for Children living with you but not of this relationship 40. Court Ordered Child Support you pay for children of another relationship. 41. Court Ordered Spousal Maintenance (Alimony) you pay 42. Miscellaneous (please list on a separate sheet and fill in total here) TOTAL PERSONAL EXPENSES CREDIT CARD DEBT you 43. TOTAL Monthly Payments on Credit Cards you GRAND TOTAL of Household, Vehicle, Insurance and Personal Expenses and Credit Card Payments Page 8 of 11

9 INCOME TAX PAYMENTS MONTHLY PAYROLL WITHHOLDING OR ESTIMATED TAXES 44. FEDERAL 45. FICA 46. MEDICARE 47. STATE OF VERMONT 48. OTHER TAXES WITHHELD/PAID CHILDREN'S EXPENSES MONTHLY EXPENSES FOR CHILDREN OF THIS RELATIONSHIP PAID BY YOU 49. Clothing and Shoes 50. Diapers 51. Out-of-Pocket Child Care Costs related to your employment 52. School lunches 53. School supplies 54. Fees/expenses for special activities (e.g., piano lessons, sports) 55. Summer Camp 56. Private School Tuition 57. Uninsured Medical/Dental Expenses 58. Child Support you pay for your children of this relationship 59. Miscellaneous: Please itemize below. Miscellaneous 1 Miscellaneous 2 Miscellaneous 3 Miscellaneous 4 TOTAL MONTHLY EXPENSES FOR CHILDREN Page 9 of 11

10 RENTAL INCOME ATTACHMENT (Schedule E) A. Line A ANNUAL RENT RECEIVED B. ANNUAL RENTAL EXPENSES 1. Cleaning and Maintenance 2. Commissions 3. Insurance 4. Legal and Other Professional Fees 5. Mortgage Interest Paid to Banks 6. Other Interest 7. Repairs 8. Supplies 9. Taxes 10. Utilities 11. Wages and Salaries 12. Other (please list) a. b. C. d. 13. Depreciation Expense TOTAL ANNUAL EXPENSES (Add Lines 1 through 13) C. Line B TOTAL ANNUAL INCOME (Line A minus Line B) Line C TOTAL MONTHLY INCOME (Line C divided by 12) Enter this amount on Page 2, B. Line 1, Section I) of Form 813A Page 10 of 11

11 A. MONTHLY GROSS RECEIPTS OR SALES B. MONTHLY BUSINESS EXPENSES 1. Cost of goods sold and/or operation 14. Office Expenses & Supplies 2. Advertising 15. Laundry & Cleaning 3. Bad debts from sales or service 16. Pension and/or profit sharing plan 4. Auto Expense: Gas Insurance Maintenance Registration 17. Rent for leased business property 18. Machinery or Equipment 19. Other Business Property 5. Commissions 20. Repairs 6. Depletion 21. Supplies 7. Depreciation 22. Taxes 8. Dues & Publications 23. Travel 9. Employee Benefit Program 24. Meals & Entertainment 10. Insurance (other than Health) (Specify) a. b. 11. Interest paid on Mortgage (to banks) 12. Other Interest Payment (Specify) 13. Legal & Professional Services 25. Utilities & Telephone 26. Wages 27. Other (List & Specify) a. b. c d. e. f. g. TOTAL MONTHLY BUSINESS EXPENSES (Add Lines 1 through 27) MONTHLY BUSINESS NET INCOME (Gross Receipts/Sales minus Expenses) Enter this amount of Page 2 A Line 3 (Section I) of Form 813A Page 11 of 11

For all types of cases, please complete Part I, attach necessary documents, and have your signature notarized on page 2.

For all types of cases, please complete Part I, attach necessary documents, and have your signature notarized on page 2. NORTH CAROLINA 14 TH JUDICIAL DISTRICT DURHAM COUNTY, Plaintiff -v-, Defendant IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION -CVD- FINANCIAL AFFIDAVIT FOR: Plaintiff Defendant TYPE OF SUPPORT

More information

IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION

IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION NORTH CAROLINA GUILFORD COUNTY Plaintiff v. Defendant IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION File No. A F FI DAVIT OF I NC OME & E X PENSES O F TH E P LA I N T IF F D E F E N DA N T (

More information

IN THE SUPERIOR COURT FOR THE COUNTY OF STATE OF GEORGIA. case No. DOMESTIC RELATIONS FINANCIAL AFFIDAVIT

IN THE SUPERIOR COURT FOR THE COUNTY OF STATE OF GEORGIA. case No. DOMESTIC RELATIONS FINANCIAL AFFIDAVIT IN THE SUPERIOR COURT FOR THE COUNTY OF STATE OF GEORGIA Plaintiff v case No. Defendant DOMESTIC RELATIONS FINANCIAL AFFIDAVIT Section 1 Affiant's Name Spouse's Name Date of Marriage Age Age Date of Separation

More information

GENERAL FINANCIAL DISCLOSURE FORM

GENERAL FINANCIAL DISCLOSURE FORM MISC THE COOLEY LAW FIRM Shelly Booth Cooley Nevada State Bar No. 8992 10161 Park Run Drive, Suite 150 Las Vegas, Nevada 89145 Telephone: (702) 265-4505/Facsimile: (702) 645-9924 E-mail: scooley@cooleylawlv.com

More information

GENERAL INSTRUCTIONS FOR COMPLETING NRCP 16.2 FINANCIAL DISCLOSURE FORM (Remove These Instructions Before Filing Form)

GENERAL INSTRUCTIONS FOR COMPLETING NRCP 16.2 FINANCIAL DISCLOSURE FORM (Remove These Instructions Before Filing Form) GENERAL INSTRUCTIONS FOR COMPLETING NRCP 16.2 FINANCIAL DISCLOSURE FORM (Remove These Instructions Before Filing Form) 1. Nevada Rule of Civil Procedure 16.2 requires that this Financial Disclosure Form

More information

Instructions for INCOME AND EXPENSE DECLARATION

Instructions for INCOME AND EXPENSE DECLARATION Instructions for INCOME AND EXPENSE DECLARATION This packet is designed to help you complete an Income and Expense Declaration [FL-150] and it includes a blank Income and Expense Declaration. An Income

More information

INITIAL CLIENT QUESTIONNAIRE Financial. Name: SSN: DOB: Spouse: SSN: DOB: Address: City: State: Zip: Length of Residence:

INITIAL CLIENT QUESTIONNAIRE Financial. Name: SSN: DOB: Spouse: SSN: DOB: Address: City: State: Zip: Length of Residence: FOR OFFICE USE ONLY Chapter 7 13 Individual Joint Attorney s Fee: Filing Fee: INITIAL CLIENT QUESTIONNAIRE Financial Date: Name: SSN: DOB: Spouse: SSN: DOB: Address: City: State: Zip: County: Length of

More information

FL-150. John Smith. George J Jones SUPERIOR COURT OF CALIFORNIA, COUNTY OF

FL-150. John Smith. George J Jones SUPERIOR COURT OF CALIFORNIA, COUNTY OF ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number and address): John Smith FOR COURT USE ONLY FL-150 CA TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): George J Jones SUPERIOR COURT

More information

Collection Information Statement for Wage Earners and Self-Employed Individuals

Collection Information Statement for Wage Earners and Self-Employed Individuals Form 433-A (Rev. December 2012) Department of the Treasury Internal Revenue Service Collection Information Statement for Wage Earners and Self-Employed Individuals Wage Earners Complete Sections 1, 2,

More information

Connecticut Judicial Branch Self-Represented Parties Information Series

Connecticut Judicial Branch Self-Represented Parties Information Series Connecticut Judicial Branch Self-Represented Parties Information Series Filling Out and Filing a Financial Affidavit Short Form Slide 1 Welcome to the Connecticut Judicial Branch Law Libraries Self-Represented

More information

IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS FINANCIAL STATEMENT GROSS INCOME

IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS FINANCIAL STATEMENT GROSS INCOME IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS IN RE THE MARRIAGE OF: and Petitioner No.: Respondent FINANCIAL STATEMENT 1 2 GROSS WAGES OR SALARY ADDITIONAL INCOME (State

More information

ONTARIO Court File Number. Form 13.1: Financial Statement (Property and Support Claims) sworn/affirmed. Applicant(s) Respondent(s)

ONTARIO Court File Number. Form 13.1: Financial Statement (Property and Support Claims) sworn/affirmed. Applicant(s) Respondent(s) ONTARIO Court File Number at (Name of court) Court office address Form 13.1: Financial Statement (Property and sworn/affirmed Applicant(s) Full legal name & address for service street & number, municipality,

More information

pages is accurate to the best of my knowledge and belief and sets out the financial situation as of (give date for which information is accurate)

pages is accurate to the best of my knowledge and belief and sets out the financial situation as of (give date for which information is accurate) ONTARIO Court File Number at (Name of Court) Court office address Form 13: Financial Statement (Support Claims) sworn/affirmed Applicant(s) Full legal name & address for service street & number, municipality,

More information

Employer: Employer telephone: Employer Address:

Employer: Employer telephone: Employer Address: NORTH CAROLINA COUNTY OF WAKE IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO. Assigned Judge: Plaintiff, v. Defendant. FINANCIAL AFFIDAVIT* OF PLAINTIFF DEFENDANT Date Completed: Employer:

More information

Form 70 I. (general heading) FINANCIAL STATEMENT OF

Form 70 I. (general heading) FINANCIAL STATEMENT OF Form 70 I (general heading) FINANCIAL STATEMENT OF INCOME AND MONEY RECEIVED (Include income and other money received from all sources, whether taxable or not, for the twelve month period ending on the

More information

UNITED STATES DISTRICT COURT for the District of

UNITED STATES DISTRICT COURT for the District of Page 1 of 5 UNITED STATES DISTRICT COURT for the District of Plaintiff/Petitioner v. Civil Action No. Defendant/Respondent APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Long

More information

HOME OWNER INFORMATION WORKSHEET

HOME OWNER INFORMATION WORKSHEET HOME OWNER INFORMATION WORKSHEET Homeowner (A) Homeowner (B) Homeowner (A) Street Address City State Zip Code Homeowner (B) Street Address City State Zip Code Property Address (if different) City State

More information

STEP 1: DOCUMENT COLLECTION

STEP 1: DOCUMENT COLLECTION STEP 1: DOCUMENT COLLECTION Because your filing will require many details and documents and because the court is both picky and strict about information, documents are needed from you. Income Tax Returns

More information

FAX: Atty. Reg. #: Division Courtroom SWORN FINANCIAL STATEMENT

FAX: Atty. Reg. #: Division Courtroom SWORN FINANCIAL STATEMENT District Court Denver Juvenile Court County, Colorado Family Court 333 Monroe St Court address 222 Newtown, PA 19323 In re: The Marriage of: Parental Responsibilities concerning: Petitioner: George J Jones

More information

AFFIDAVIT IN SUPPORT OF APPLICATION FOR SETTLEMENT

AFFIDAVIT IN SUPPORT OF APPLICATION FOR SETTLEMENT Financial Service Commission of Ontario Commission des services financiers de l'ontario AFFIDAVIT IN SUPPORT OF APPLICATION FOR SETTLEMENT THE MOTOR VEHICLE ACCIDENT CLAIMS ACT R.S.O. 1990, CHAPTER M.41,

More information

DEBT: GARNISHMENT & EXECUTION

DEBT: GARNISHMENT & EXECUTION DEBT: GARNISHMENT & EXECUTION How Does a Creditor Collect a Debt? Sometimes, the person or company to whom you owe money will go to court. They will ask for a court order to make you pay your debt. For

More information

Compromise Application

Compromise Application Compromise Application Before we will consider accepting less than the full amount due, we must receive all of the information requested below. Your documentation will be reviewed and verified. A Revenue

More information

Personal Information. Name Soc. Sec. No. Date of Birth Occupation Work Phone Taxpayer: Spouse: Street Address City State Zip

Personal Information. Name Soc. Sec. No. Date of Birth Occupation Work Phone Taxpayer: Spouse: Street Address City State Zip Paid to Taxpayer Paid to Spouse Client Tax Organizer Please complete this Organizer before your appointment. Prior year clients should use a personalized Organizer. To request a personalized Organizer,

More information

Collection Information Statement for Wage Earners and Self-Employed Individuals

Collection Information Statement for Wage Earners and Self-Employed Individuals Georgia Department of Revenue Collection Information Statement for Wage Earners and SelfEmployed Individuals Form CD14C (June 2012) Use this form if you are An individual who owes income tax on a Form

More information

PERSONAL FINANCIAL ORGANIZER

PERSONAL FINANCIAL ORGANIZER PERSONAL FINANCIAL ORGANIZER SENIOR SOLUTIONS OF AMERICA, INC. www.todaysseniors.com COPYRIGHT 2007 SENIOR SOLUTIONS OF AMERICA, INC. ALL RIGHTS RESERVED. ORGANIZING YOUR PERSONAL FINANCES Are your financial

More information

Names of all Co-owners w/ Address (if different)

Names of all Co-owners w/ Address (if different) Foreclosure Prevention Intake Form I. CLIENT INFORMATION Date: Name(s) Address Home Phone Work Phone Best Times to Reach Marital Status Spouse (if any) Children (names and ages) Others in Household: II.

More information

PERSONAL FINANCIAL WORKSHEET

PERSONAL FINANCIAL WORKSHEET PERSONAL FINANCIAL WORKSHEET This is NOT the Personal Financial Statement required for DBE certification and cannot be substituted for the mandatory Personal Financial Statement. This document is intended

More information

ONTARIO Court File Number. Form 13.1: Financial Statement (Property and Support Claims) sworn/affirmed. Applicant(s) Respondent(s)

ONTARIO Court File Number. Form 13.1: Financial Statement (Property and Support Claims) sworn/affirmed. Applicant(s) Respondent(s) ONTARIO Court File Number at (Name of court) Court office address Form 13.1: Financial Statement (Property and sworn/affirmed Applicant(s) Full legal name & address for service street & number, municipality,

More information

Pre-Bankruptcy Filing Certification Credit Counseling DISCLOSURE AGREEMENT

Pre-Bankruptcy Filing Certification Credit Counseling DISCLOSURE AGREEMENT Pre-Bankruptcy Filing Certification Credit Counseling DISCLOSURE AGREEMENT Thank you for contacting Comprehensive Credit Counseling of Rural Services of Indiana, Inc. for you Pre- Bankruptcy Filing Certification.

More information

Tax Return Questionnaire - 2013 Tax Year

Tax Return Questionnaire - 2013 Tax Year Print this form out, take some time to fill it out, and bring it with you when you come to the office. This will save you time and money, and help us help you more effectively. Tax Return Questionnaire

More information

3. If you received any interest from a "Seller Financed" mortgage, provide: Name and Address of Payer Social Security Number Amount

3. If you received any interest from a Seller Financed mortgage, provide: Name and Address of Payer Social Security Number Amount Print this form out, take some time to fill it out, and bring it with you when you come to the office. This will save you time and money, and help us help you more effectively. Tax Return Questionnaire

More information

Financial Goal Setting Worksheet

Financial Goal Setting Worksheet Financial Goal Setting Worksheet SMART goals are.. Specific states exactly what is to be achieved. Measurable the dollar amount needed is included in the goal. Attainable determine how a goal can be reached.

More information

Tax Preparation Checklist

Tax Preparation Checklist Tax Preparation Checklist Being prepared for tax season could expedite your return and reduce your taxes. We have prepared a list of common items that are present with most returns. Taxpayer Checklist

More information

CLIENT INFORMATION OFFICE USE ONLY. TODAY'S DATE: Name: Any other names you may be known by: INFORMATION ABOUT YOU: SS#

CLIENT INFORMATION OFFICE USE ONLY. TODAY'S DATE: Name: Any other names you may be known by: INFORMATION ABOUT YOU: SS# CLIENT INFORMATION INFORMATION ABOUT YOU: TODAY'S DATE: Name: Any other names you may be known by: SS# Date of Birth Physical Address Mailing (if different) City State Phone #s Hm Cell Wk E-mail address

More information

Divorce Information and Worksheet

Divorce Information and Worksheet Divorce Information and Worksheet Instructions: This worksheet is designed to be used by persons contemplating a divorce. It may also be used by your attorney. Completing this form before your initial

More information

Total Monthly Income $ Miscellaneous Income Royalties, Trusts, and Other Investments $ Contributions from Others $ Dependent Children s monthly gross

Total Monthly Income $ Miscellaneous Income Royalties, Trusts, and Other Investments $ Contributions from Others $ Dependent Children s monthly gross District Court Denver Juvenile Court County, Colorado Court Address: In re: The Marriage of: The Civil Union of: Parental Responsibilities concerning: Petitioner: and Co-Petitioner/Respondent: Attorney

More information

TRANSMITTAL OF FINANCIAL REPORTS AND CERTIFICATION OF COMPLIANCE WITH UNITED STATES TRUSTEE OPERATING REQUIREMENTS FOR THE PERIOD ENDED:

TRANSMITTAL OF FINANCIAL REPORTS AND CERTIFICATION OF COMPLIANCE WITH UNITED STATES TRUSTEE OPERATING REQUIREMENTS FOR THE PERIOD ENDED: TRANSMITTAL OF FINANCIAL REPORTS AND CERTIFICATION OF COMPLIANCE WITH UNITED STATES TRUSTEE OPERATING REQUIREMENTS FOR THE PERIOD ENDED: IN RE: : CASE NO.: : Chapter 11 Judge: : Debtor : As debtor in possession,

More information

Denver Tax Group, LLC CHADWICK ELLIOTT 1888 Sherman Street SUITE 650 DENVER, CO 80203 (0) Organizer Mailing Slip

Denver Tax Group, LLC CHADWICK ELLIOTT 1888 Sherman Street SUITE 650 DENVER, CO 80203 (0) Organizer Mailing Slip Denver Tax Group, LLC CHADWICK ELLIOTT Sherman Street SUITE 0 DENVER, CO 00, (0) Organizer Mailing Slip TAX ORGANIZER TO:, FROM: Denver Tax Group, LLC Sherman Street SUITE 0 DENVER CO 00 (0) -0 Enclosed

More information

Designing Your Budget

Designing Your Budget 2 Designing Your Budget Budgeting is needed to get the most mileage out of your income. It is your road map for managing your money. Planning your spending is called Budgeting. Smart investing@your library

More information

c. Homeowners Insurance

c. Homeowners Insurance AFFIDAVIT BEFORE ME, the undersigned authority, personally came and appeared the undersigned who, being by me first duly sworn, did depose and say that the following is a true and correct statement of

More information

LOSS MITIGATION APPLICATION

LOSS MITIGATION APPLICATION Loan Number: {1} LOSS MITIGATION APPLICATION COMPLETE ALL PAGES OF THIS FORM See Instructions corresponding with numbers in brackets {} on form BORROWER {3} CO BORROWER {4} Borrower s Name Co Borrower

More information

Tax Return Questionnaire - 2015 Tax Year

Tax Return Questionnaire - 2015 Tax Year SPECTRUM Spectrum Financial Resources LLP FINANCIAL 15021 Ventura Boulevard #341 310.963.4322 T RESOURCES Sherman Oaks, CA 91403 303.942.4322 F www.spectrum-cpa.com Tax Return Questionnaire - 2015 Tax

More information

WSSS Policy on Tuition Assistance. Procedure

WSSS Policy on Tuition Assistance. Procedure WSSS Policy on Tuition Assistance Each family, regardless of its financial situation, is an important part of the Waldorf School of Saratoga Springs. Families who feel unable to pay full tuition are invited

More information

Social Security Number: Occupation: Email Address: Current Address (if not listed on W2 form or 1099 Taxpayer Name: Spouse Name: form):

Social Security Number: Occupation: Email Address: Current Address (if not listed on W2 form or 1099 Taxpayer Name: Spouse Name: form): For New Clients only - please submit with your forms and documentations TAX RETURN QUESTIONNAIRE - TAX YEAR 2014 Current Address (if not listed on W2 form or 1099 Taxpayer Name: Spouse Name: form): Phone

More information

Page 1 OLSON CPAs, PLLC CERTIFIED PUBLIC ACCOUNTANTS 2015 INCOME TAX ORGANIZER ********************************************************

Page 1 OLSON CPAs, PLLC CERTIFIED PUBLIC ACCOUNTANTS 2015 INCOME TAX ORGANIZER ******************************************************** Page 1 OLSON CPAs, PLLC CERTIFIED PUBLIC ACCOUNTANTS 2015 INCOME TAX ORGANIZER ******************************************************** Client Name: E-mail: Telephone: Day Evening NOTES: If we DID NOT

More information

Income Tax Organizer

Income Tax Organizer Income Tax Organizer This organizer will help you organize your tax information (and make sure that you don't miss important deductions). We hope you find it useful and informative! (This form was prepared

More information

To see if you qualify for this program, send the items listed below to Northwest Savings Bank.

To see if you qualify for this program, send the items listed below to Northwest Savings Bank. COMPLETE YOUR CHECKLIST We need this information to help you modify your mortgage payment. To see if you qualify for this program, send the items listed below to Northwest Savings Bank. 1. The enclosed

More information

INSTRUCTIONS FOR COMPLETION OF FINANCIAL DECLARATION FOR MURPHY LAW FIRM

INSTRUCTIONS FOR COMPLETION OF FINANCIAL DECLARATION FOR MURPHY LAW FIRM INSTRUCTIONS FOR COMPLETION OF FINANCIAL DECLARATION FOR MURPHY LAW FIRM GENERAL INFORMATION. You only need to complete your side of the Financial Declaration (for example, if you are the Mother, you will

More information

MONTANA JUDICIAL DISTRICT COURT COUNTY

MONTANA JUDICIAL DISTRICT COURT COUNTY Name Address City State Zip Code Phone Number [ ] PETITIONER/[ ] RESPONDENT PRO SE MONTANA JUDICIAL DISTRICT COURT COUNTY In re the Marriage of:, Petitioner, and, Respondent. Cause No.: [ ] Petitioner

More information

MONTANA JUDICIAL DISTRICT COURT COUNTY

MONTANA JUDICIAL DISTRICT COURT COUNTY Name Address City State Zip Code Phone Number WIFE, PETITIONER PRO SE Name Address City State Zip Code Phone Number HUSBAND, PETITIONER PRO SE MONTANA JUDICIAL DISTRICT COURT COUNTY In re the Marriage

More information

INSERT SECTION DAILY EXPENDITURES TRACKING SHEETS EXPENSE WORKSHEET INCOME WORKSHEET

INSERT SECTION DAILY EXPENDITURES TRACKING SHEETS EXPENSE WORKSHEET INCOME WORKSHEET INSERT SECTION DAILY EXPENDITURES TRACKING SHEETS EXPENSE WORKSHEET INCOME WORKSHEET U N D E R S T A N D I N G M O N E Y A N D C R E D I T R E F E R E N C E G U I D E 17 Record Of Daily Expenditures MONTH

More information

I, (full name) am am not currently employed. I am employed hours per week. I am paid weekly bi-weekly twice a month monthly.

I, (full name) am am not currently employed. I am employed hours per week. I am paid weekly bi-weekly twice a month monthly. District Court Denver Juvenile Court County, Colorado Court Address: In re: The Marriage of: Parental Responsibilities concerning: Petitioner: and Co-Petitioner/Respondent: Attorney or Party Without Attorney

More information

MARK S. ZUCKERBERG, P.C. ATTORNEY AT LAW

MARK S. ZUCKERBERG, P.C. ATTORNEY AT LAW LAW OFFICE OF MARK S. ZUCKERBERG, P.C. ATTORNEY AT LAW Full Legal Name: (Last, First, Middle) Spouse's Full Legal Name: (Last, First Middle) All other names used in the past 6 years: All other names used

More information

FINANCIAL AID APPLICATION for ECE, HYC, Camp, and JCC Maccabi Games and ArtsFest

FINANCIAL AID APPLICATION for ECE, HYC, Camp, and JCC Maccabi Games and ArtsFest FINANCIAL AID APPLICATION for ECE, HYC, Camp, and JCC Maccabi Games and ArtsFest Financial Aid Checklist In order for this application to be reviewed, you must have already submitted all registration forms

More information

Income Sources Recap Jot down your streams of income, even if it s just a trickle right now.

Income Sources Recap Jot down your streams of income, even if it s just a trickle right now. Income Sources Recap Jot down your streams of income, even if it s just a trickle right now. Money s fun. If you ve got some. You ve got money coming in from somewhere, right? Then write it down. This

More information

SERVE THIS FORM ON THE OTHER PARTY. DO NOT FILE WITH THE COURT. INTERIM MONTHLY INCOME AND EXPENSES STATEMENT 1 (fixed percentage for child expenses)

SERVE THIS FORM ON THE OTHER PARTY. DO NOT FILE WITH THE COURT. INTERIM MONTHLY INCOME AND EXPENSES STATEMENT 1 (fixed percentage for child expenses) 4A-212. Interim monthly income and expenses statement. [For use with Rule 1-122 NMRA] STATE OF NEW MEXICO COUNTY OF JUDICIAL DISTRICT, Petitioner, v. No., Respondent. SERVE THIS FORM ON THE OTHER PARTY.

More information

TOWN OF GORHAM NEW HAMPSHIRE

TOWN OF GORHAM NEW HAMPSHIRE TOWN OF GORHAM NEW HAMPSHIRE APPLICATION FOR PUBLIC ASSISTANCE CASE # Date of Application Referred by 1. General Information: Name Date of Birth Address Telephone Social Security number US Citizen? Marital

More information

ONTARIO Ontario Family Court of the Superior Court of Justice INSTRUCTIONS

ONTARIO Ontario Family Court of the Superior Court of Justice INSTRUCTIONS at ONTARIO Ontario Family Court of the Superior Court of Justice 161 Elgin Street, Ottawa, Ontario, K2P 2K1 Court File Number 04FL1234 (Name of Court) Family Law Rules, O. Reg. 114/99 (Court office address)

More information

PRE-BANKRUPTCY CONSULTATION FORM

PRE-BANKRUPTCY CONSULTATION FORM TOLL FREE - 1 (888) 713-7137 PRE-BANKRUPTCY CONSULTATION FORM Personal Information Name: last first middle initial Address: Social Security No. street city zip - - Phone: Email: Marital status: single

More information

Statement of Financial Circumstances (Centrelink reviews)

Statement of Financial Circumstances (Centrelink reviews) Statement of Financial Circumstances (Centrelink reviews) If the decision under review is about a debt, your financial circumstances may be relevant to the AAT s decision. It will be helpful if you fill

More information

Please complete this Organizer before your appointment. Street Address City State ZIP Home Phone

Please complete this Organizer before your appointment. Street Address City State ZIP Home Phone Womack Tax Prep LLC Client Tax Organizer Please complete this Organizer before your appointment. 1. Personal Information Name Soc. Sec.. Date of Birth Occupation Work Phone Taxpayer Spouse Street Address

More information

INFORMATION ABOUT YOU

INFORMATION ABOUT YOU NOTE: With this type of form, to be completed by the client you would want the top portion to approximate your letterhead in case someone picked up this form for another to complete or some other reason

More information

{REMOVE THIS 1 page cover memo before sending to applicant/rp} DIVISION OF WASTE MANAGEMENT & DISTRICT PERSONNEL

{REMOVE THIS 1 page cover memo before sending to applicant/rp} DIVISION OF WASTE MANAGEMENT & DISTRICT PERSONNEL MEMORANDUM {REMOVE THIS 1 page cover memo before sending to applicant/rp} TO: FROM: SUBJECT: DIVISION OF WASTE MANAGEMENT & DISTRICT PERSONNEL OFFICE OF GENERAL COUNSEL / OFFICE OF INSPECTOR GENERAL FINANCIAL

More information

Personal Information - Client - Page 1. Employment. Education. Military Service. Children & Dependents

Personal Information - Client - Page 1. Employment. Education. Military Service. Children & Dependents Personal Information - Client - Page Date Mr. Mrs. Ms. First Name M.I. Last Name Birth Date Age S.S. Number Street Address City/Town Home Phone Cell Phone State/Zip Fax Email Address Employment Occupation

More information

STATEMENT OF CURRENT MONTHLY INCOME AND CALCULATION OF COMMITMENT PERIOD AND DISPOSABLE INCOME

STATEMENT OF CURRENT MONTHLY INCOME AND CALCULATION OF COMMITMENT PERIOD AND DISPOSABLE INCOME Form B22C (Chapter 13) (10/05) In re Debtor(s) Case Number: (If known) According to the calculations required by this statement: The applicable commitment period is 3 years. The applicable commitment period

More information

Sample Only. Grant & Aid Application For the School Year Beginning Fall 2012. Save Time Apply Online. Information needed to complete your application:

Sample Only. Grant & Aid Application For the School Year Beginning Fall 2012. Save Time Apply Online. Information needed to complete your application: 10000028406 Save Time Apply Online. Apply online at www.factstuitionaid.com - Applying online is the fastest and most direct method of submitting your application. It allows your institution to view your

More information

DATE OF APPOINTMENT (MM/DD/YYYY) INVENTORY VALUES AS OF DATE (MM/DD/YYYY) FILING DUE DATE (MM/DD/YYYY)

DATE OF APPOINTMENT (MM/DD/YYYY) INVENTORY VALUES AS OF DATE (MM/DD/YYYY) FILING DUE DATE (MM/DD/YYYY) District Court Denver Probate Court County, Colorado Court Address: In the Interest of: Protected Person Attorney or Party Without Attorney (Name and Address): Case Number: COURT USE ONLY Phone Number:

More information

Borrower Assistance Package

Borrower Assistance Package Borrower Assistance Package In order for us to properly evaluate your request for assistance with your mortgage loan or home equity loan, you must complete the enclosed forms and return it promptly to

More information

M. Caroline Cantrell & Associates, PC Attorney at Law

M. Caroline Cantrell & Associates, PC Attorney at Law M. Caroline Cantrell & Associates, PC Attorney at Law 8800 SE Sunnyside Road, Suite 207N, Clackamas, OR 97015 (503) 236-9211 549 NW 2nd Avenue, Canby Oregon 97013 (503) 266-0382 Date: PENDING FORECLOSURE,

More information

ONTARIO Court File Number. Form 13: Financial Statement (Support Claims) sworn/affirmed. Applicant(s) Respondent(s)

ONTARIO Court File Number. Form 13: Financial Statement (Support Claims) sworn/affirmed. Applicant(s) Respondent(s) ONTARIO Court File Number at (Name of Court) Court office address Form 13: Financial Statement (Support Claims) sworn/affirmed Applicant(s) Full legal name & address for service street & number, municipality,

More information

Effective Strategies for Personal Money Management

Effective Strategies for Personal Money Management Effective Strategies for Personal Money Management The key to successful money management is developing and following a personal financial plan. Research has shown that people with a financial plan tend

More information

THE ABC S OF VEHICLE FINANCING CURRICULUM. Counting Your Money

THE ABC S OF VEHICLE FINANCING CURRICULUM. Counting Your Money Counting Your Money Section Objectives Counting your money and managing your money wisely is the most important part of your trip on the road to personal financial success. It is a critical step in achieving

More information

Debtor s Full Legal Name: Spouse s Full Legal Name: Other Names Ever Used: Email: Tel#: Cell#: Emergency Contact (name & number):

Debtor s Full Legal Name: Spouse s Full Legal Name: Other Names Ever Used: Email: Tel#: Cell#: Emergency Contact (name & number): Law Office of Jeffrey B. Kelly, P.C. Chapter 7 Chapter 13 Bankruptcy Questionnaire DEBTOR INFO: How did you first hear about my office? Office Location Debtor s Full Legal Name: SS# DOB: Spouse s Full

More information

APPLICATION FOR FINANCIAL ASSISTANCE

APPLICATION FOR FINANCIAL ASSISTANCE APPLICATION FOR FINANCIAL ASSISTANCE Name of Student(s): Current Year(s): Current School(s): Parent and Fee Payer Details Parent(s) Father Surname: First name: Address: Mother Surname: First name: Address:

More information

DIVORCE GUIDE SUPPLEMENT

DIVORCE GUIDE SUPPLEMENT A PUBLICATION OF THE JUDICIAL BRANCH STATE OF CONNECTICUT Do It Yourself DIVORCE GUIDE SUPPLEMENT (To be used with the Do It Yourself Divorce Guide) JDP-FM-180 (Rev. 2/15) s2 DO IT YOURSELF DIVORCE SUPPLEMENT

More information

COMPLETING A BC SUPREME COURT FINANCIAL STATEMENT: WHY? HOW? WHAT HAPPENS NEXT?

COMPLETING A BC SUPREME COURT FINANCIAL STATEMENT: WHY? HOW? WHAT HAPPENS NEXT? COMPLETING A BC SUPREME COURT FINANCIAL STATEMENT: WHY? HOW? WHAT HAPPENS NEXT? WHY? Are you wondering why your lawyer has asked you to complete a BC Supreme Court Financial Statement ( FS ) when you have

More information

Federal Home Loan Bank of Chicago Community Investment. DPP Income Calculation Guidelines

Federal Home Loan Bank of Chicago Community Investment. DPP Income Calculation Guidelines Federal Home Loan Bank of Chicago Community Investment DPP Income Calculation Guidelines TABLE OF CONTENTS I. Income Eligibility Requirements II. Basis for Income Eligibility A. Determining Household Size

More information

Financial Planning. Introduction. Learning Objectives

Financial Planning. Introduction. Learning Objectives Financial Planning Introduction Financial Planning Learning Objectives Lesson 1 Budgeting: How to Live on Your Own and Not Move Home in a Week Prepare a budget and determine disposable income. Identify

More information

SAMPLE ONLY. FACTS Grant & Aid Application For the School Year Beginning Fall 2015. Save Time Apply Online.

SAMPLE ONLY. FACTS Grant & Aid Application For the School Year Beginning Fall 2015. Save Time Apply Online. 10000028406 Save Time Apply Online. Apply online at online.factsmgt.com/aid w available in Spanish. Applying online allows your institution to view your application electronically within minutes of submission.

More information

Answering Questions about Your Family s Income When Applying for Health Insurance

Answering Questions about Your Family s Income When Applying for Health Insurance What You Need to Know about Health Insurance Applying for Health Insurance Answering Questions about Your Family s Income When Applying for Health Insurance About this fact sheet You may be able to get

More information

Financial Aid Application 2008-09

Financial Aid Application 2008-09 AlfredUniversity Financial Aid Application 2008-09 Student Financial Aid Office Alfred University Saxon Drive Alfred, NY 14802 PHONE: (607) 871-2159 FAX: (607) 871-2252 www.alfred.edu 1. 2. Name Last First

More information

Schedule C Worksheet for Self-Employed Filers and Contractors tax year 2013. Part 1: Business Income and Expenses

Schedule C Worksheet for Self-Employed Filers and Contractors tax year 2013. Part 1: Business Income and Expenses Schedule C Worksheet for Self-Employed Filers and Contractors tax year 2013 This document will list and explain the information and documentation that we will need in order to file a tax return for a self-employed

More information

FULLER LANDAU LLP. Tax Return Questionnaire - 2014 Tax Year. Name and Address: Social Security Occupation Number:

FULLER LANDAU LLP. Tax Return Questionnaire - 2014 Tax Year. Name and Address: Social Security Occupation Number: FULLER LANDAU LLP Print this form out, take some time to fill it out, and bring it with you when you come to the office. This will save you time and money, and help us help you more effectively. Tax Return

More information

ONLY. FACTS Grant & Aid Application For the School Year Beginning Fall 2014. Save Time Apply Online.

ONLY. FACTS Grant & Aid Application For the School Year Beginning Fall 2014. Save Time Apply Online. 10000028406 Save Time Apply Online. Apply online at online.factsmgt.com/aid w available in Spanish. Applying online allows your institution to view your application electronically within minutes of submission.

More information

1420 n. CLAREMONT BLVD., SUITE 101-B TEL (909) 398-4737 CLAREMONT, CALIFORNIA 91711 FAX (909) 398-4733

1420 n. CLAREMONT BLVD., SUITE 101-B TEL (909) 398-4737 CLAREMONT, CALIFORNIA 91711 FAX (909) 398-4733 1420 n. CLAREMONT BLVD., SUITE 101-B TEL (909) 398-4737 CLAREMONT, CALIFORNIA 91711 FAX (909) 398-4733 www.nicholscpas.com Email: info@nicholscpas.com January 12, 2015 RE: 2014 Tax Returns It is hard to

More information

Tax Preparation by Robin G Wixom, LLC

Tax Preparation by Robin G Wixom, LLC Tax Preparation by Robin G Wixom, LLC 2015 TAX ORGANIZER Please fill out the following questionnaire and gather the applicable documents. If you choose to send the documents via e-mail, please encrypt

More information

Your Monthly Income. Consumer Credit Counseling Basic Budgeting Forms. Monthly Income Source

Your Monthly Income. Consumer Credit Counseling Basic Budgeting Forms. Monthly Income Source Your Income Income Source Income Required Planned Net Income Head of Household net income (income less taxes, etc) Household Second net Income (income less taxes, etc) Third household net income Child

More information

Patient Assistance (Charity Care) Program 2015

Patient Assistance (Charity Care) Program 2015 Patient Assistance Program (Charity Care) Program Overview This procedure addresses Northeastern Vermont Regional Hospital s (NVRH) Patient Assistance or Charity Care Program. Charity Care is defined as

More information

(b) The request for a support order through high school graduation may be filed before or after the child s 18 th birthday.

(b) The request for a support order through high school graduation may be filed before or after the child s 18 th birthday. Texas Family Code Subchapter A. Court-Ordered Child Support 154.001. Support of Child. (a) The court may order either or both parents to support a child in the manner specified by the order: (1) until

More information

Child Support Computation 03EN025I

Child Support Computation 03EN025I Child Support Computation 03EN025I Purpose of form The purpose of the Child Support Computation form is to calculate a child support obligation pursuant to 43 O.S. Sections 118A 118I, effective July 1,

More information

BOARD OF REVIEW DECLARATION OF POVERTY & REQUEST FOR TAX RELIEF APPLICATION

BOARD OF REVIEW DECLARATION OF POVERTY & REQUEST FOR TAX RELIEF APPLICATION BOARD OF REVIEW DECLARATION OF POVERTY & REQUEST FOR TAX RELIEF APPLICATION Property ID Number: Current SEV: Current Taxable Value: Property Address: APPLICANT INFORMATION: IMPORTANT: It is necessary that

More information

Verification that property taxes and HOA fees are current Verification that the mortgage is current or mortgage satisfaction letter from lender

Verification that property taxes and HOA fees are current Verification that the mortgage is current or mortgage satisfaction letter from lender You must submit a completed City of Lauderhill Application. You are required to submit COPIES of the following documents for your program of interest, along with the General Requirements to participate

More information

Tax Resolution Underwriting Worksheet

Tax Resolution Underwriting Worksheet Tax Resolution Underwriting Worksheet Office: Tax Consultant: Date: Personal Information Spouse info Taxpayer's name DOB SSN Filing Status (SINGLE, JOINTLY, SEPARATELY) Address Home Phone Number Cell Phone

More information

FREE CARE APPLICATION ATTACHMENT

FREE CARE APPLICATION ATTACHMENT FREE CARE APPLICATION ATTACHMENT PLEASE REMEMBER THIS IS NOT AN INSURANCE PLAN IT IS A CHARITABLE CARE PROGRAM AND THERE IS NO ESTABLISHED FUND. THERE IS NO MONEY EXCHANGED FOR SERVICES BY ANY CMC PHYSICIAN/PRACTICE.

More information

BANKRUPTCY INTAKE FORM

BANKRUPTCY INTAKE FORM BANKRUPTCY INTAKE FORM Instructions: Fill out this form in its entirety. Upon completion, you may fax the form with a cover sheet with my name on it to (804) 796 6775, you may email the form to my attention

More information

Banning Law Firm. 10801 Lomas NE Ste. 104 Albuquerque, NM 87112 Office 883-9577 Fax 866-677-0508

Banning Law Firm. 10801 Lomas NE Ste. 104 Albuquerque, NM 87112 Office 883-9577 Fax 866-677-0508 Banning Law Firm 10801 Lomas NE Ste. 104 Albuquerque, NM 87112 Office 883-9577 Fax 866-677-0508 Questionnaire Taxes Credit Report Paper Work Needed To File Counseling Certificate Pay Check Stubs Payment

More information

RYAN & GRINDE, LTD. A T T O R N E Y S A T L A W

RYAN & GRINDE, LTD. A T T O R N E Y S A T L A W RYAN & GRINDE, LTD. A T T O R N E Y S A T L A W James P. Ryan, Jr. 407 14 th Street NW (507) 282-8118 Paul H. Grinde Post Office Box 6667 (507) 282-2275 FAX Kristine L. Dicke Rochester, Minnesota 55903-6667

More information

Request for Innocent Spouse Relief

Request for Innocent Spouse Relief Form 8857 (Rev. January 2014) Department of the Treasury Internal Revenue Service (99) Request for Innocent Spouse Relief Information about Form 8857 and its separate instructions is at www.irs.gov/form8857.

More information

Client Tax Organizer If you have rental property or are self-employed, please request additional organizers.

Client Tax Organizer If you have rental property or are self-employed, please request additional organizers. Client Tax Organizer If you have rental property or are self-employed, please request additional organizers. 1. Personal Information Name Soc. Sec.. Date of Birth Occupation Work Phone Taxpayer Spouse

More information

How to Fill out the Child Support Guidelines Affidavit. Form DR-305

How to Fill out the Child Support Guidelines Affidavit. Form DR-305 How to Fill out the Child Support Guidelines Affidavit Form DR-305 Child Support Guidelines Affidavit, DR- 305 form (PDF Fill-In PDF 651 KB) Child Support Guidelines Affidavit, DR- 305 form (PDF Fill-In

More information